The old documentation list are really to much and about nursing process those documentation allow just some of information to document, like some of nursing intervention and some of patient data. Also there is going to implement Health Information System. Any practical sample will be beneficially.

This site may help in the process of assessment

http://www.nursediscovery.com/publication-2/

I attach one page of ISDA (Intan's Screening Diagnoses Assessment)

Regards

Intan

Dear Agron, I think that a good approach can to be the N.N.N. Alliance. You can use for clinical nursing practice the Gordon's "Functional Health Pattens" for nursing assessment, NANDA-I nursing standard language for nursing diagnoses, NOC for choises of patient outcomes, and NIC for nursing interventions used. These classifications of diagnoses, outcomes, and interventions are useful to improve a quick recording of nurses's activities or daily care plans in the traditional documents as well as in Electronic Clinical Record. Many nurses have published interesting studies on NANDA, NOC, and NIC linkages. Further information about the links among the three languages are available through the Center for Nursing Classification and Clinical Effectiveness at The University of Iowa ( www.nursing.uiowa.edu/cnc ). Regards. Nicola